Effectiveness of hygiene kit distribution to reduce cholera transmission in Kasaï-Oriental, Democratic Republic of Congo, 2018: a prospective cohort study

Effect of a Water, Sanitation, and Hygiene Program on Handwashing with a Cleansing Agent among Diarrhea Patients and Attendants in Healthcare Facilities in the Democratic Republic of the Congo: A Randomized Pilot of the PICHA7 Program

Healthcare-acquired infections are a major problem in healthcare facility settings around the world. The Democratic Republic of the Congo (DRC) has over 2 million diarrhea patients hospitalized each year. These healthcare settings become high-risk environments for spreading diarrheal illnesses such as cholera. The objective of the Preventative Intervention for Cholera for 7 Days (PICHA7) program is to develop evidence-based water, sanitation, and hygiene (WASH) interventions to reduce cholera and other severe diarrheal diseases in the DRC. The study objective was to evaluate the effectiveness of PICHA7 program delivery in increasing handwashing with a cleansing agent at stool/vomit- and food-related events in a healthcare facility setting among diarrhea patients and patient attendants. A pilot of the PICHA7 program was conducted among 284 participants in 27 healthcare facilities from March 2020 to November 2021 in urban Bukavu in the South Kivu Province of the DRC. The standard arm received the standard message provided in the DRC to diarrhea patients on the use of oral rehydration solution and a basic WASH message at healthcare facility discharge. The PICHA7 arm received the PICHA7 WASH pictorial module delivered by a health promoter focused on handwashing with a cleansing agent at the bedside of the diarrhea patient in the healthcare facility and provision of a soapy water bottle (water and detergent powder). Within 24 h of intervention delivery, a three-hour structured observation of handwashing practices at stool/vomit- and food-related events (key events) was conducted in healthcare facilities of diarrhea patients and their attendants. Compared to the standard arm, there was significantly more handwashing with a cleansing agent at key events in the PICHA7 arm (40% vs. 15%) (odds ratio: 5.04; (95% confidence interval (CI): 2.01, 12.7)). These findings demonstrate that delivery of the PICHA7 WASH pictorial module and provision of a soapy water bottle to diarrhea patients and their attendants presents a promising approach to increase handwashing with a cleansing agent among this high-risk population in healthcare facilities in the eastern DRC.

A Quantitative and Qualitative Program Evaluation of a Case-Area Targeted Intervention to Reduce Cholera in Eastern Democratic Republic of the Congo

Individuals living near cholera patients have an increased risk of cholera infections. Case-area targeted interventions (CATIs) promoting improved water, sanitation, and hygiene (WASH) present a promising approach to reducing cholera for those residing near cholera cases. However, there is limited evidence on the effectiveness and implementation of this approach in increasing WASH behaviors. We conducted a mixed-methods program evaluation in rural and urban eastern Democratic Republic of the Congo. The quantitative component included household structured observations and spot checks in CATI and control areas to assess WASH conditions and behaviors. The qualitative component included semi-structured interviews with CATI recipients, non-recipients, and implementers to assess CATI implementation. A total of 399 participants were enrolled in the quantitative evaluation conducted within 1 month of CATI delivery. For the qualitative evaluation, 41 semi-structured interviews were conducted, 30 with individuals in CATI areas (recipients and non-recipients) and 11 with CATI implementers. Handwashing with soap was low among both CATI and control area participants (1% vs. 2%, p = 0.89). Significantly more CATI area households (75%) had chlorine tablets present compared to control area households (0%) (p < 0.0001); however, the percentage of households with stored water free chlorine concentrations > 0.2 mg/L was low for both CATI and control area households (11% vs. 6%, p = 0.45). Implementers reported an insufficient supply of soap for distribution to recipients and mistrust in the community of their activities. CATI recipients demonstrated low knowledge of the correct preparation and use of chlorine for water treatment. Recipients also indicated a need for CATI implementers to engage community leaders. As CATIs are part of cholera control plans in many cholera-endemic countries, it is important to evaluate existing programs and develop evidence-based approaches to deliver CATIs that are both tailored to the local context and engage affected communities to increase WASH behaviors to reduce the spread of cholera.

Randomized Controlled Trial of the Cholera-Hospital-Based-Intervention-for-7-Days (CHoBI7) Cholera Rapid Response Program to Reduce Diarrheal Diseases in Bangladesh

(a) Objective: To build an evidence base on effective water, sanitation, and hygiene interventions to reduce diarrheal diseases in cholera hotspots, we developed the CHoBI7 Cholera Rapid Response Program. (b) Methods: Once a cholera patient (confirmed by bacterial culture) is identified at a health facility, a health promoter delivers a targeted WASH intervention to the cholera hotspot (households within 20 m of a cholera patient) through both in-person visits during the first week and bi-weekly WASH mobile messages for the 3-month program period. A randomized controlled trial of the CHoBI7 Cholera Rapid Response Program was conducted with 284 participants in 15 cholera hotspots around cholera patients in urban Dhaka, Bangladesh. This program was compared to the standard message in Bangladesh on the use of oral rehydration solution for dehydration. Five-hour structured observation of handwashing with soap and diarrhea surveillance was conducted monthly. (c) Findings: Handwashing with soap at food- and stool-related events was significantly higher in the CHoBI7 Cholera Rapid Response Program arm compared to the standard message arm at all timepoints (overall 54% in the CHoBI7 arm vs. 23% in the standard arm, p < 0.05). Furthermore, there was a significant reduction in diarrheal prevalence for all participants (adults and children) (Prevalence Ratio (PR) 0.35, 95% CI: 0.14-0.85) and for children under 5 years of age (PR: 0.27, 95% CI: 0.085-0.87) during the 3-month program. (d) Conclusions: These findings demonstrate that the CHoBI7 Cholera Rapid Response Program is effective in lowering diarrhea prevalence and increasing handwashing with soap for a population at high risk of cholera.

Formative Research for the Development of Evidence-Based Targeted Water, Sanitation, and Hygiene Interventions to Reduce Cholera in Hotspots in the Democratic Republic of the Congo: Preventative Intervention for Cholera for 7 Days (PICHA7) Program

Compared to the general public, household members of cholera patients are at a 100 times higher risk of contracting cholera during the 7-day high-risk period after a cholera patient has been admitted to a health facility for treatment. The Preventative-Intervention-for-Cholera-for-7-days (PICHA7) program aims to reduce household transmission of cholera during this 7-day high-risk period through a health facility-initiated water, sanitation, and hygiene (WASH) program promoting handwashing with soap, water treatment, and safe water storage. The PICHA7 program is delivered to cholera patient households through: (1) a pictorial flipbook delivered by a health promoter; (2) a cholera prevention package (handwashing station, drinking water vessel with lid and tap, and chlorine tablets); and (3) weekly WASH mobile messages sent to patient households in the Democratic Republic of the Congo (DRC). The objectives of this study were to conduct formative research to identify facilitators and barriers of the promoted WASH behaviors for cholera patient households and to tailor the PICHA7 program to target these facilitators and barriers. Formative research included 93 semi-structured interviews with diarrhea patient households and healthcare workers during exploratory research and a pilot study of 518 participants. Barriers to the promoted WASH behaviors identified during exploratory and pilot study interviews included: (1) low awareness of cholera transmission and prevention; (2) unaffordability of soap for handwashing; and (3) intermittent access to water limiting water for handwashing. For intervention development, narratives of the lived experiences of patient households in our study were presented by health promoters to describe cholera transmission and prevention, and soapy water and ash were promoted in the program flipbook and mobile messages to address the affordability of soap for handwashing. A jerry can was provided to allow for additional water storage, and a tap with a slower flow rate was attached to the handwashing station to reduce the amount of water required for handwashing. The pilot findings indicate that the PICHA7 program has high user acceptability and is feasible to deliver to cholera patients that present at health facilities for treatment in our study setting. Formative research allowed for tailoring this targeted WASH program for cholera patient households in the DRC.

Effectiveness of case-area targeted interventions including vaccination on the control of epidemic cholera: protocol for a prospective observational study

INTRODUCTION

Cholera outbreaks in fragile settings are prone to rapid expansion. Case-area targeted interventions (CATIs) have been proposed as a rapid and efficient response strategy to halt or substantially reduce the size of small outbreaks. CATI aims to deliver synergistic interventions (eg, water, sanitation, and hygiene interventions, vaccination, and antibiotic chemoprophylaxis) to households in a 100-250 m 'ring' around primary outbreak cases.

METHODS AND ANALYSIS

We report on a protocol for a prospective observational study of the effectiveness of CATI. Médecins Sans Frontières (MSF) plans to implement CATI in the Democratic Republic of the Congo (DRC), Cameroon, Niger and Zimbabwe. This study will run in parallel to each implementation. The primary outcome is the cumulative incidence of cholera in each CATI ring. CATI will be triggered immediately on notification of a case in a new area. As with most real-world interventions, there will be delays to response as the strategy is rolled out. We will compare the cumulative incidence among rings as a function of response delay, as a proxy for performance. Cross-sectional household surveys will measure population-based coverage. Cohort studies will measure effects on reducing incidence among household contacts and changes in antimicrobial resistance.

ETHICS AND DISSEMINATION

The ethics review boards of MSF and the London School of Hygiene and Tropical Medicine have approved a generic protocol. The DRC and Niger-specific versions have been approved by the respective national ethics review boards. Approvals are in process for Cameroon and Zimbabwe. The study findings will be disseminated to the networks of national cholera control actors and the Global Task Force for Cholera Control using meetings and policy briefs, to the scientific community using journal articles, and to communities via community meetings.

How does handwashing behaviour change in response to a cholera outbreak? A qualitative case study in the Democratic Republic of the Congo

Background

Handwashing with soap has the potential to curb cholera transmission. This research explores how populations experienced and responded to the 2017 cholera outbreak in the Democratic Republic of the Congo and how this affected their handwashing behaviour.

Methods

Cholera cases were identified through local cholera treatment centre records. Comparison individuals were recruited from the same neighbourhoods by identifying households with no recent confirmed or suspected cholera cases. Multiple qualitative methods were employed to understand hand hygiene practices and their determinants, including unstructured observations, interviews and focus group discussions. The data collection tools and analysis were informed by the Behaviour Centred Design Framework. Comparisons were made between the experiences and practices of people from case households and participants from comparison households.

Results

Cholera was well understood by the population and viewed as a persistent and common health challenge. Handwashing with soap was generally observed to be rare during the outbreak despite self-reported increases in behaviour. Across case and comparison groups, individuals were unable to prioritise handwashing due to competing food-scarcity and livelihood challenges and there was little in the physical or social environments to cue handwashing or make it a convenient, rewarding or desirable to practice. The ability of people from case households to practice handwashing was further constrained by their exposure to cholera which in addition to illness, caused profound non-health impacts to household income, productivity, social status, and their sense of control.

Conclusions

Even though cholera outbreaks can cause disruptions to many determinants of behaviour, these shifts do not automatically facilitate an increase in preventative behaviours like handwashing with soap. Hygiene programmes targeting outbreaks within complex crises could be strengthened by acknowledging the emic experiences of the disease and adopting sustainable solutions which build upon local disease coping mechanisms.